中国全科医学
中國全科醫學
중국전과의학
CHINESE GENERAL PRACTICE
2014年
20期
2349-2352
,共4页
陈章强%洪浪%王洪%陆林祥%尹秋林%赖珩莉%李华泰
陳章彊%洪浪%王洪%陸林祥%尹鞦林%賴珩莉%李華泰
진장강%홍랑%왕홍%륙림상%윤추림%뢰형리%리화태
风湿性心脏病%二尖瓣狭窄%三尖瓣闭锁不全%血管形成术,经腔,经皮冠状动脉
風濕性心髒病%二尖瓣狹窄%三尖瓣閉鎖不全%血管形成術,經腔,經皮冠狀動脈
풍습성심장병%이첨판협착%삼첨판폐쇄불전%혈관형성술,경강,경피관상동맥
Rheumaticheartdisease%mitralvalvestenosis%Tricuspidvalveinsufficiency%Angioplasty,translumi-nal,percutaneous coronary
目的:探讨风湿性心脏病左房室瓣狭窄合并右房室瓣反流患者中左房室瓣球囊扩张术( PBmV)的应用价值。方法选择2000年1月-2012年6月在江西省人民院因风湿性心脏病左房室瓣狭窄住院行PBmV的患者1700例,其中220例合并右房室瓣反流,男90例,女130例;年龄29~67岁,平均(47.5±7.4)岁;左房室瓣口面积0.4~1.5 cm2,平均(0.9±0.3)cm2;右房室瓣反流面积3.2~26.0 cm2,平均(11.2±6.5)cm2。以造影剂递增法扩张,扩张终点使左房压( LAP)下降50%以上,或左心房平均压降到15 mm Hg(1 mm Hg=0.133 kPa)以下,左房室瓣区舒张期隆隆样杂音消失或明显减轻。对于合并右房室瓣重度反流患者,联合使用利尿剂,保持每天2000 ml以上的尿量。术后2~3 d内用经胸超声心动图复查左房室瓣口面积( mVA)、右房室瓣反流面积( TRA)、LAP、左房直径( LAD)、右房压( RAP)、右房直径( RAD)、肺动脉压( PAP)以及左心室射血分数( LVEF)。PBmV术后定期电话或门诊随访,随访6个月~9年,平均(75±32)个月,并在随访结束时经彩色多普勒超声心动图复查上述指标。结果220例患者PBmV后mVA较术前显著增加(P﹤0.01)。对于轻中度右房室瓣反流者,术后TRA较术前显著减少(P﹤0.01);对于重度右房室瓣反流者,术后TRA与术前相比差别无统计学意义(P﹥0.05)。术后LAP、RAP、LAD、RAD均较术前减小,差异有统计学意义(P﹤0.01);PAP患者从术前压力(60.6±15.5)mm Hg降低到术后的(48.2±10.3)mm Hg(P﹤0.01)。舒张期隆隆样杂音从中重度减为轻度,胸闷、气促、呼吸困难等症状明显缓解,心功能明显改善。随访过程中,合并轻中度右房室瓣反流患者中有2例失访,合并重度右房室瓣反流患者中有2例死亡(大面积脑梗死1例,心力衰竭1例,分别在术后第6年和第8年死亡)。随访结束时 mVA较术后有所减小( P﹤0.05);LAD、RAD较术后轻度增大(P﹤0.05),但均未及术前水平;TRA、PAP以及LVEF与术后比较无差异(P﹥0.05)。结论 PBmV治疗风湿性心脏病左房室瓣中重度狭窄合并轻中度右房室瓣反流患者,可以减轻症状,减轻TRA,疗效肯定;对于合并右房室瓣重度反流患者,也可以改善生活质量,近中期疗效可以,远期疗效有待于进一步观察。
目的:探討風濕性心髒病左房室瓣狹窄閤併右房室瓣反流患者中左房室瓣毬囊擴張術( PBmV)的應用價值。方法選擇2000年1月-2012年6月在江西省人民院因風濕性心髒病左房室瓣狹窄住院行PBmV的患者1700例,其中220例閤併右房室瓣反流,男90例,女130例;年齡29~67歲,平均(47.5±7.4)歲;左房室瓣口麵積0.4~1.5 cm2,平均(0.9±0.3)cm2;右房室瓣反流麵積3.2~26.0 cm2,平均(11.2±6.5)cm2。以造影劑遞增法擴張,擴張終點使左房壓( LAP)下降50%以上,或左心房平均壓降到15 mm Hg(1 mm Hg=0.133 kPa)以下,左房室瓣區舒張期隆隆樣雜音消失或明顯減輕。對于閤併右房室瓣重度反流患者,聯閤使用利尿劑,保持每天2000 ml以上的尿量。術後2~3 d內用經胸超聲心動圖複查左房室瓣口麵積( mVA)、右房室瓣反流麵積( TRA)、LAP、左房直徑( LAD)、右房壓( RAP)、右房直徑( RAD)、肺動脈壓( PAP)以及左心室射血分數( LVEF)。PBmV術後定期電話或門診隨訪,隨訪6箇月~9年,平均(75±32)箇月,併在隨訪結束時經綵色多普勒超聲心動圖複查上述指標。結果220例患者PBmV後mVA較術前顯著增加(P﹤0.01)。對于輕中度右房室瓣反流者,術後TRA較術前顯著減少(P﹤0.01);對于重度右房室瓣反流者,術後TRA與術前相比差彆無統計學意義(P﹥0.05)。術後LAP、RAP、LAD、RAD均較術前減小,差異有統計學意義(P﹤0.01);PAP患者從術前壓力(60.6±15.5)mm Hg降低到術後的(48.2±10.3)mm Hg(P﹤0.01)。舒張期隆隆樣雜音從中重度減為輕度,胸悶、氣促、呼吸睏難等癥狀明顯緩解,心功能明顯改善。隨訪過程中,閤併輕中度右房室瓣反流患者中有2例失訪,閤併重度右房室瓣反流患者中有2例死亡(大麵積腦梗死1例,心力衰竭1例,分彆在術後第6年和第8年死亡)。隨訪結束時 mVA較術後有所減小( P﹤0.05);LAD、RAD較術後輕度增大(P﹤0.05),但均未及術前水平;TRA、PAP以及LVEF與術後比較無差異(P﹥0.05)。結論 PBmV治療風濕性心髒病左房室瓣中重度狹窄閤併輕中度右房室瓣反流患者,可以減輕癥狀,減輕TRA,療效肯定;對于閤併右房室瓣重度反流患者,也可以改善生活質量,近中期療效可以,遠期療效有待于進一步觀察。
목적:탐토풍습성심장병좌방실판협착합병우방실판반류환자중좌방실판구낭확장술( PBmV)적응용개치。방법선택2000년1월-2012년6월재강서성인민원인풍습성심장병좌방실판협착주원행PBmV적환자1700례,기중220례합병우방실판반류,남90례,녀130례;년령29~67세,평균(47.5±7.4)세;좌방실판구면적0.4~1.5 cm2,평균(0.9±0.3)cm2;우방실판반류면적3.2~26.0 cm2,평균(11.2±6.5)cm2。이조영제체증법확장,확장종점사좌방압( LAP)하강50%이상,혹좌심방평균압강도15 mm Hg(1 mm Hg=0.133 kPa)이하,좌방실판구서장기륭륭양잡음소실혹명현감경。대우합병우방실판중도반류환자,연합사용이뇨제,보지매천2000 ml이상적뇨량。술후2~3 d내용경흉초성심동도복사좌방실판구면적( mVA)、우방실판반류면적( TRA)、LAP、좌방직경( LAD)、우방압( RAP)、우방직경( RAD)、폐동맥압( PAP)이급좌심실사혈분수( LVEF)。PBmV술후정기전화혹문진수방,수방6개월~9년,평균(75±32)개월,병재수방결속시경채색다보륵초성심동도복사상술지표。결과220례환자PBmV후mVA교술전현저증가(P﹤0.01)。대우경중도우방실판반류자,술후TRA교술전현저감소(P﹤0.01);대우중도우방실판반류자,술후TRA여술전상비차별무통계학의의(P﹥0.05)。술후LAP、RAP、LAD、RAD균교술전감소,차이유통계학의의(P﹤0.01);PAP환자종술전압력(60.6±15.5)mm Hg강저도술후적(48.2±10.3)mm Hg(P﹤0.01)。서장기륭륭양잡음종중중도감위경도,흉민、기촉、호흡곤난등증상명현완해,심공능명현개선。수방과정중,합병경중도우방실판반류환자중유2례실방,합병중도우방실판반류환자중유2례사망(대면적뇌경사1례,심력쇠갈1례,분별재술후제6년화제8년사망)。수방결속시 mVA교술후유소감소( P﹤0.05);LAD、RAD교술후경도증대(P﹤0.05),단균미급술전수평;TRA、PAP이급LVEF여술후비교무차이(P﹥0.05)。결론 PBmV치료풍습성심장병좌방실판중중도협착합병경중도우방실판반류환자,가이감경증상,감경TRA,료효긍정;대우합병우방실판중도반류환자,야가이개선생활질량,근중기료효가이,원기료효유대우진일보관찰。
Objective Toinvestigatetheapplicationvalueofpercutaneousballoonmitralvalvuloplasty(PBmV)in rheumatic heart disease( RHD) patients combined with mitral valve stenosis( mVS)and tricuspid regurgitation( TR). Meth-ods Atotalof1700patientshadPBmVduetomVSfromJanuary2000toJune2012,including220combinedwithTR,90 males,130 females,aged 29~67 years,averagely(47. 5 ±7. 4)years old. Their mitral valvular area(mVA)was 0. 4~1. 5 cm2,mean(0. 9 ±0. 3)cm2;tricuspid regurgitation area(TRA)3. 2~26. 0 cm2,mean(11. 2 ±6. 5)cm2. Contract agent incremental method was used to make left atrial pressure decrease by 50%,or decrease to 15 mm Hg(1 mm Hg=0. 133 kPa)or less,and diastolic rumbling murmur disappeared or decreased remarkably in left atrioventricular valve area. For those combined with right atrioventricular valve regurgitation,conjunctive use of diuretics to maintain urine output over 2 000 ml per day. Within days 2~3 after operation,transthoracic echocardiography was used to review mVA,TRA,left atrial diameter( LAD),right atrial diameter( RAD),pulmonary artery pressure( PAP),left ventricular ejection fraction( LVEF). Telephone or outpatient follow-ups were regular after PBmV,lasting 6~9 years,averagely(75 ± 32) months. At the end of the follow-ups,the a-boveindicatorswerereviewedbycolorDopplerechocardiography.Results In220patientscombinedwithTR,mVAincreased significantly after PBmV(P﹤0. 01). TRA reduced significantly in patients with mild,moderate TR(P﹤0. 01),but there was not significant difference in patients with severe TR between post- and pre-operations(P﹥0. 05). LAP,RAP,LAD, RAD decreased as compared with those before operation,the difference was significant(P﹤0. 01). PAP reduced from pre-operative(60. 6 ±15. 5)mm Hg to post-operative(48. 2 ±10. 3)mm Hg(P﹤0. 01). Diastolic rumbling murmur reduced from severe to mild,the symptoms of chest tightness,anhelation,dyspnea etc. relieved and heart function improved significant-ly. In follow-ups,2 patients with mild or moderate TA were lost,2 with severe TA died(1 died of massive cerebral infarction in years 6,1 of heart failure in years 8). mVA decreased to some extent at the end of follow-ups(P﹤0. 05);LAD,RAD increased slightly(P﹤0. 05),but lower than before operation;there was not significant difference in TRA,PAP LVEF be-tweenpre-andpost-operation(P﹥0.05).Conclusion PBmVcandecreasesymptomandTRAwithdefiniteeffectsintreat-ment of RHD patients with moderate or severe mVS and mild or moderate TR,and improve the quality of life of severe TA patients with good recent- and mid-term effect. Its long-term effects remain to be seen.